nutch_noindex
CANCEL
COVID-2019 Alert

Information about the 2019 Novel Coronavirus. Read the latest >

/nutch_noindex

Barbara Sourkes, PhD

  • Barbara M Sourkes

Specialties

Psychology

Work and Education

Internship

Boston Children's Hospital, Boston, MA, 1976

Residency

Boston Children's Hospital, Boston, MA, 1979

All Publications

Opportunities for Quality Improvement in Bereavement Care at a Children's Hospital: Assessment of interdisciplinary staff perspectives JOURNAL OF PALLIATIVE CARE Contro, N., Sourkes, B. M. 2012; 28 (1): 28-35

Abstract

This study examined the current state of bereavement care at a university-based children's hospital from the perspective of the interdisciplinary staff. In all, 60 staff members from multiple disciplines participated in in-depth interviews. In at least two-thirds of the interviews, issues related to the bereavement experience of both staff and families emerged and were consistently identified. Themes included: disparities in bereavement care based on relationship factors; logistics of time and space; geographical distances; the different cultures and languages of families; continuity in family follow-up; needs of siblings and other family members; staff communication, cooperation, and care coordination; staff suffering; and education, mentoring, and support for staff. This evidence-based needs assessment furnishes an empirical basis for the design and implementation of bereavement services for both families and staff. It can serve as a template for evaluation at other children's hospitals and thus contribute to the sound and creative development of the field of pediatric palliative care.

View details for Web of Science ID 000302444100005

View details for PubMedID 22582469

Textbook of Interdisciplinary Pediatric Palliative Care Wolfe, Hinds, Sourkes 2011

View details for PubMedID 16301200

Pediatric Palliative Care Textbook of Pediatric Psychosomatic Medicine Consultation on Physically Ill Children Brown, Sourkes 2010

Abstract

Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.

View details for DOI 10.1097/MAT.0000000000001092

View details for PubMedID 31789655

Special Care Considerations for the Dying Child. Handbook of Psychiatry in Palliative Medicine: Second Edition Sourkes, Wolfe 2009

Abstract

Most pediatric clinicians aspire to promote the physical, emotional, and developmental well-being of children, hoping to bestow a long and healthy life. Yet, some infants, children, and adolescents confront life-threatening illnesses and life-shortening conditions. Over the past 70 years, the clinician's response to the suffering of these children has evolved from veritable neglect to the development of pediatric palliative care as a subspecialty devoted to their care. In this article, we review the history of how clinicians have understood and responded to the suffering of children with serious illnesses, highlighting how an initially narrow focus on anxiety eventually transformed into a holistic, multidimensional awareness of suffering. Through this transition, and influenced by the adult hospice movement, pediatric palliative care emerged as a new discipline. Becoming a discipline, however, has not been a panacea. We conclude by highlighting challenges remaining for the next generation of pediatric palliative care professionals to address.

View details for DOI 10.1542/peds.2019-1741

View details for PubMedID 31806669

Food, toys, and love: pediatric palliative care. Current problems in pediatric and adolescent health care Sourkes, B., Frankel, L., Brown, M., Contro, N., Benitz, W., Case, C., Good, J., Jones, L., Komejan, J., Modderman-Marshall, J., Reichard, W., Sentivany-Collins, S., Sunde, C. 2005; 35 (9): 350-386

Abstract

Pediatric palliative care is a comprehensive treatment approach (physical, psychological, social, spiritual) for children living with life-threatening conditions. These patients and siblings, as well as children of ill parents, face extraordinary psychological challenges. Structured art techniques incorporated into psychotherapy can be powerful for children dealing with life-and-death realities. This article provides the rationale, instructions, and examples for 3 techniques that the author has adapted for children facing illness and bereavement. Although these art techniques are simple to administer, they frequently evoke complex and powerful responses and thus are intended for use by or in consultation with mental health professionals.

View details for PubMedID 30219217

Armfuls of Time: The Psychological Experience of the Child with a Life-threatening Illness Sourkes 1995

Abstract

Children who live with a complex chronic or life-threatening illness face extraordinary challenges. Whether they are receiving disease-oriented treatment (aimed at potential cure or prolongation of life) or palliative treatment-or both concurrently-our challenge is to enhance their comfort and minimize their distress. Symptom management is thus a critical component of pediatric palliative care. Symptoms may be either physical or psychological in nature (or a confluence of both) and their effective management has a direct impact on the child's quality of life. This article provides an integrative overview of children's experience of selected physical and psychological symptoms, as expressed through their words and images. Understanding their perspectives is an essential component in the design and provision of optimal symptom management. Included, as well, are examples from siblings-a reminder of the profound impact of illness on these children who also "live" the experience, albeit in a different way. The symptoms that are described are pain, nausea and vomiting, fatigue, weakness, seizures, hair loss, depression, and anxiety. Although psychological symptoms are often inextricable from the physical, they may also present independently as part of the overall illness experience.

View details for PubMedID 29671836

The Deepening Shade: Pyschological Aspects of Life-Threatening Illness Sourkes 1982
Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience. ASAIO journal (American Society for Artificial Internal Organs : 1992) Knoll, C., Kaufman, B., Chen, S., Murray, J., Cohen, H., Sourkes, B. M., Rosenthal, D. N., Hollander, S. A. 2019

Abstract

Pediatric fellows receive little palliative care (PC) education and have few opportunities to practice communication skills.In this pilot study, we assessed (1) the relative effectiveness of simulation-based versus didactic education, (2) communication skill retention, and (3) effect on PC consultation rates.Thirty-five pediatric fellows in cardiology, critical care, hematology/oncology, and neonatology at two institutions enrolled: 17 in the intervention (simulation-based) group (single institution) and 18 in the control (didactic education) group (second institution). Intervention group participants participated in a two-day program over three months (three simulations and videotaped PC panel). Control group participants received written education designed to be similar in content and time.(1) Self-assessment questionnaires were completed at baseline, post-intervention and three months; mean between-group differences for each outcome measure were assessed. (2) External reviewers rated simulation-group encounters on nine communication domains. Within-group changes over time were assessed. (3) The simulation-based site's PC consultations were compared in the six months pre- and post-intervention.Compared to the control group, participants in the intervention group improved in self-efficacy (p=0.003) and perceived adequacy of medical education (p<0.001), but not knowledge (p=0.20). Reviewers noted nonsustained improvement in four domains: relationship building (p=0.01), opening discussion (p=0.03), gathering information (p=0.01), and communicating accurate information (p=0.04). PC consultation rate increased 64%, an improvement when normalized to average daily census (p=0.04).This simulation-based curriculum is an effective method for improving PC comfort, education, and consults. More frequent practice is likely needed to lead to sustained improvements in communication competence.

View details for DOI 10.1089/jpm.2016.0556

View details for PubMedID 28436742

Response to Suffering of the Seriously Ill Child: A History of Palliative Care for Children. Pediatrics Sisk, B. A., Feudtner, C., Bluebond-Langner, M., Sourkes, B., Hinds, P. S., Wolfe, J. 2019

Abstract

Despite advances in therapies, many pediatric heart transplant (Htx) recipients will die prematurely. We characterized the circumstances surrounding death in this cohort, including location of death and interventions performed in the final 24hours.We reviewed all patients who underwent Htx at Lucile Packard Children's Hospital, Stanford, survived hospital discharge, and subsequently died between July 19, 2007 and September 13, 2015. The primary outcome studied was location of death, characterized as inpatient, outpatient, or emergency department. Circumstances of death (withdrawal of life-sustaining treatment, death during resuscitation, or death without resuscitation with/without do not resuscitate) and interventions performed in the last 24hours of life were also analyzed.Twenty-three patients met the entry criteria. The median age at death was 12 (range 2-20) years, and the median time between transplant and death was 2.8 (range 0.8-11) years. Four (17%) died at home, and three (13%) died in the emergency department. Sixteen (70%) patients died in the hospital, 14 of 16 (88%) of whom died in an intensive care unit. Five of 23 (22%) patients experienced attempted resuscitation. Interventions performed in the last 24hours of life included intubation (74%), mechanical support (30%), and dialysis (22%). Most patients had a recent outpatient clinical encounter with normal graft function within 60days of dying.Death in children after Htx often occurs in the inpatient setting, particularly the intensive care unit. Medical interventions, including attempted resuscitation, are common at the end of life. Given the difficulty in anticipating life-threatening events, earlier discussions with patients regarding end-of-life wishes are appropriate, even in those with normal graft function.

View details for DOI 10.1016/j.jpainsymman.2016.12.334

View details for PubMedID 28063864

Children's Artwork: Its Value in Psychotherapy in Pediatric Palliative Care. Child and adolescent psychiatric clinics of North America Sourkes, B. M. 2018; 27 (4): 55165

Abstract

Despite greatly improved survival in pediatric patients with end-stage heart failure through the use of ventricular assist devices (VADs), heart failure ultimately remains a life-threatening disease with a significant symptom burden. With increased demand for donor organs, liberalizing the boundaries of case complexity, and the introduction of destination therapy in children, more children can be expected to die while on mechanical support. Despite this trend, guidelines on the ethical and pragmatic issues of compassionate deactivation of VAD support in children are strikingly absent. As VAD support for pediatric patients increases in frequency, the pediatric heart failure and palliative care communities must work toward establishing guidelines to clarify the complex issues surrounding compassionate deactivation. Patient, family and clinician attitudes must be ascertained and education regarding the psychological, legal and ethical issues should be provided. Furthermore, pediatric-specific planning documents for use before VAD implantation as well as deactivation checklists should be developed to assist with decision-making at critical points during the illness trajectory. Herein we review the relevant literature regarding compassionate deactivation with a specific focus on issues related to children.

View details for DOI 10.1016/j.healun.2016.03.020

View details for Web of Science ID 000376951900004

View details for PubMedID 27197773

Children's Experience of Symptoms: Narratives through Words and Images. Children (Basel, Switzerland) Sourkes, B. M. 2018; 5 (4)
Training Pediatric Fellows in Palliative Care: a Comparison of Simulation-Based Training and Didactic Education Brock, K., Cohen, H., Sourkes, B., Good, J., Halamek, L. WILEY. 2017: S65S66
Training Pediatric Fellows in Palliative Care: A Pilot Comparison of Simulation Training and Didactic Education. Journal of palliative medicine Brock, K. E., Cohen, H. J., Sourkes, B. M., Good, J. J., Halamek, L. P. 2017

View details for DOI 10.1177/0009922814534767

View details for PubMedID 24817074

The End of Life Experience of Pediatric Heart Transplant Recipients. Journal of pain and symptom management Hollander, S. A., Dykes, J., Chen, S., Barkoff, L., Sourkes, B., Cohen, H., Rosenthal, D. N., Bernstein, D., Kaufman, B. D. 2017

Abstract

Burnout is a work-related syndrome characterized by emotional exhaustion (EE), depersonalization (DP), and lack of personal accomplishment (PA). We hypothesized that the transition into an environment of high physical, intellectual, and emotional demands of the medical profession would lead to an increase in the prevalence of burnout in pediatric residents, which would remain high throughout residency.The Maslach Burnout Inventory (MBI) was administered to pediatric residents at Lucile Packard Children's Hospital 6 times between February 2010 and February 2012. These times corresponded to the start of residency, mid-intern year, end-intern year, mid-junior year, end-junior year, and mid-senior year.Mean values of burnout components changed significantly between the start of residency and mid-intern year. EE increased from 15.8 to 24.5 (P < .001), DP increased from 4.5 to 9.2 (P < .001), and PA decreased from 40.2 to 38.3 (P = .04). Similarly, the prevalence of burnout increased from 17% to 46% (P = .012), or 2% to 24% (P = .002) using more restrictive criteria, between the start of residency and mid-intern year. Significant changes in mean scores or prevalence of burnout were not found between any other consecutive times throughout residency.This longitudinal study documented a significant increase in the components of burnout among pediatric residents between the start of residency and mid-intern year, which persisted through the PGY2 and PGY3 years. Further studies are warranted to identify correlates of resident burnout and to develop preventative strategies to reduce its occurrence.

View details for DOI 10.1016/j.acap.2013.12.001

View details for PubMedID 24602580

Compassionate deactivation of ventricular assist devices in pediatric patients JOURNAL OF HEART AND LUNG TRANSPLANTATION Hollander, S. A., Axelrod, D. M., Bernstein, D., Cohen, H. J., Sourkes, B., Reddy, S., Magnus, D., Rosenthal, D. N., Kaufman, B. D. 2016; 35 (5): 564-567

Abstract

While conducting a grounded theory study of Chinese American and Mexican American families' experiences in pediatric palliative care, we encountered a number of unanticipated challenges regarding project development, Institutional Review Boards, recruitment, data collection, and data analysis. In this article, we describe our experiences, strategies, and insights for the benefit of other researchers and clinicians in the field.

View details for DOI 10.1177/1049732308327346

View details for Web of Science ID 000261732300002

View details for PubMedID 19001106

Improving Training in Palliative Care for Pediatric Fellows - A Simulation-Based Multi-Institution Trial Brock, K., Cohen, H., Sourkes, B., Good, J., Halamek, L. ELSEVIER SCIENCE INC. 2016: 32324

Abstract

To examine the chronic illness literature and evaluate the impact on single parenting and children and adolescents with chronic illness.We conducted literature reviews of relevant research pertaining to single-parent families on PubMed, Medline, and PsychINFO and also surveyed pertinent book chapters and all of the articles from the Journal of Pediatric Psychology since 1987 for articles, specifically examining the potential associations of single (lone) parenting versus two-parent households on children's psychosocial functioning and the impact of the child's illness on caregiver functioning.While the literature has examined and discussed the stressors associated with parenting a child with an illness, including the impact of illness on finances, family roles, and caregiver burden, few studies have examined single parents of children and adolescents with chronic illnesses and related stressors stemming from being a lone caregiver.There is a dearth of studies examining the association between lone parenting and psychosocial functioning among children and adolescents with chronic illnesses. Specific questions necessitating future investigation are summarized and recommendations are made for future research in this important area of inquiry.

View details for DOI 10.1093/jpepsy/jsm079

View details for Web of Science ID 000254714100010

View details for PubMedID 17906331

A Multidisciplinary Care Team Perspective on Children's Emotional Experience in Isolation for Stem Cell Transplantation 2015 BMT Tandem Meetings Savig, E. S., Gurevitch, J. H., Jackson, J. E., Malinowski, A., Ju, W. G., Leifer, L. J., Cohen, H. J., Sourkes, B. M., Agarwal-Hashmi, R. 2015: S180

Abstract

The Pediatric Palliative Care Curriculum (PPCC) was introduced as a pilot study in response to the published need for increased pediatric education in end-of-life (EOL) care. The PPCC was designed to better train residents in EOL issues so they could become more comfortable and knowledgeable in caring for children and adolescents with life-threatening illnesses.The PPCC consisted of six hour-long sessions run by a clinical psychologist, a licensed social worker, and faculty with experience in EOL care. The curriculum repeated every 6 weeks for 1 year. Residents in the training program at Stanford University rotating through oncology, pulmonology, and pediatric intensive care unit (PICU) were invited to attend. Session topics included: (1) personal coping skills, (2) being a caring professional, (3) recognizing cultural and familial differences, (4) pain management, (5) practical issues, and (6) meeting a bereaved parent. Pretest and posttest surveys with five-point Likert scale questions were used to measure curricular impact.Statistically significant improvement was found in resident self-report of: feeling prepared to initiate do-not-resuscitate discussions (p

View details for DOI 10.1089/jpm.2007.0194

View details for Web of Science ID 000254651600010

View details for PubMedID 18333729

Palliative care is critical to the changing face of child mortality and morbidity in the United States. Clinical pediatrics Bogetz, J. F., Schroeder, A. R., Bergman, D. A., Cohen, H. J., Sourkes, B. 2014; 53 (11): 1030-1031

View details for DOI 10.1159/000104546

View details for Web of Science ID 000248838900008

Burnout in pediatric residents over a 2-year period: a longitudinal study. Academic pediatrics Pantaleoni, J. L., Augustine, E. M., Sourkes, B. M., Bachrach, L. K. 2014; 14 (2): 167-172

Abstract

Psychotherapy for children who have life-threatening illness is unique in its challenges and rich in its rewards. Most of these children enter into psychotherapy because of the stress engendered by the illness rather than more general intrapsychic or interpersonal concerns. The facilitation of psychological adjustment is a common goal and brought about by managing anxiety related to great un-certainty and anticipatory grief. Siblings and other family members are incorporated into the work as they play a pivotal role in sustaining and strengthening emotional resources. Critical losses.around control, personal identity, and interpersonal relationships are common themes throughout the therapeutic process.

View details for DOI 10.1016/j.chc.2006.02.004

View details for Web of Science ID 000239131600005

View details for PubMedID 16797440

The Psychological Impact of Life-Limiting Conditions on the Child Oxford Textbook of Pediatric Palliative Care: Second Edition Aldridge, Sourkes 2012

Abstract

Development of a pediatric palliative care program was preceded by a needs assessment that included a staff survey and family interviews regarding improving pediatric palliative care.Four hundred forty-six staff members and community physicians responded to a written survey regarding comfort and expertise in delivering end of life care. Sixty-eight family members of 44 deceased children were interviewed regarding treatment, transition to palliative care, and bereavement follow-up contact. Frequencies were generated for responses to the staff survey. Five interviewers reviewed the families' narratives and identified frequently occurring themes.Staff members reported feeling inexperienced in communicating with patients and families about end of life issues, transition to palliative care, and do not resuscitate status. Families reported distress caused by uncaring delivery of bad news and careless remarks made by staff members. Staff members reported feeling inexperienced in symptom and pain management and described occasions when pain could have been better managed. Families believed pain had been managed as well as possible despite observing their children suffer. Fifty-four percent of staff members reported that adequate support was not provided for those who treat dying children. Staff members and family members stated their desire for more support. Staff members who described their most difficult experiences caring for a dying child referenced personal pain and inadequate support most frequently.Albeit from different perspectives, staff members and family members shared common concerns and experiences regarding pediatric palliative care. These experiences emphasize the need for additional systematic study, improved education and support for staff members, and continued development of more effective and compassionate delivery of pediatric palliative care.

View details for DOI 10.1542/peds.2003-0857-L

View details for Web of Science ID 000224842700008

View details for PubMedID 15520103

Principles of Psychotherapy Psycho-Oncology (2nd edition), Strada, Sourkes 2010

Abstract

In children and adolescents non-compliance with treatment is a major concern. To shed light on its mechanisms, we present a family demonstrating non-compliance.B, a 10 year-old boy, treated for medulloblastoma, refused high-dose chemotherapy and Autologous Bone Marrow Transplantation. Six psychotherapeutic interviews with B, his parents and staff resolved the causative issues.B's behavior expressed his parents' ambivalence, despite their informed consent. Their reasons were conscious and unconscious, rational and irrational, linked to both the past and present experiences. The mother was convinced that he would die. The discussions helped both parents to assume their parental role, B perceived their ability to truly accept the treatment and support him.Non-compliance should not be viewed as a child's or parents' intrapsychic problem, but as the result of multi-determined interaction between the child, the parents, the staff interacting with present and past events. When the child's death is a possibility, the parents' ambivalence confuses their understanding and acception of the therapy. The development of confidence between the staff, the child and parents and clear agreement about the goals of therapy is necessary to avoid the occurrence of and escalation of non-compliance, which raises difficult clinical, legal and ethical questions.

View details for Web of Science ID 000176964100011

View details for PubMedID 12135865

Away from Home: Experiences of Mexican American Families in Pediatric Palliative Care. J. Social Work in End-of-Life and Palliative Care Contro, Davies, Larson, Sourkes 2010; 6 (3): 185-204

Abstract

As a prelude to establishing a Pediatric Palliative Care Program, we solicited information from families about their experiences and their suggestions for improving the quality of end-of-life care. Participants were English- and Spanish-speaking family members of deceased pediatric patients who received care at Lucile Salter Packard Children's Hospital, Stanford University Medical Center, Palo Alto, Calif.Sixty-eight family members of 44 deceased children were interviewed regarding treatment, transition to palliative care, and bereavement follow-up. Four clinical social workers and one clinical psychologist reviewed the participants' responses and identified frequently occurring themes.Several areas of unsatisfactory interactions with staff were identified: confusing, inadequate, or uncaring communications regarding treatment or prognosis; preventable oversights in procedures or policies; failure to include or meet the needs of siblings and Spanish-speaking family members; and inconsistent bereavement follow-up. A discrepancy emerged between the high degree of pain described by the families and parents' perceptions that pain had been managed well. Community hospice programs are frequently poorly prepared to serve pediatric patients.There is a need to improve pediatric palliative care. Recurring themes in the family interviews suggest useful issues to consider in the development of a palliative care program.

View details for Web of Science ID 000173079600005

View details for PubMedID 11772185

Palliative Care for the Child with Advanced Cancer Principles and Practice of Pediatric Oncology: Sixth Edition Ulrich, Sourkes, Wolfe 2010
Psychotherapy in the Palliative Care Setting Primary Psychiatry Sourkes, Strada 2009; 16 (5): 34-40
Conducting a Qualitative Culture Study of Pediatric Palliative Care 16th International Congress on Care of the Terminally Ill Davies, B., Larson, J., Contro, N., Reyes-Hailey, C., Ablin, A. R., Chesla, C. A., Sourkes, B., Cohen, H. SAGE PUBLICATIONS INC. 2009: 516
Conducting a Qualitative Culture Study of Pediatric Palliative Care Qualitative Health Research Davies, Larson, Contro, Ablin, Chesla, Sourkes, Cohen 2009; 19: 5-16
Single parents of children with chronic illness: An understudied phenomenon JOURNAL OF PEDIATRIC PSYCHOLOGY Brown, R. T., Wiener, L., Kupst, M. J., Brennan, T., Behrman, R., Compas, B. E., Elkin, T. D., Fairclough, D. L., Friebert, S., Katz, E., Kazak, A. E., Madan-Swain, A., Mansfield, N., Mullins, L. L., Noll, R., Patenaude, A. F., Phipps, S., Sahler, O. J., Sourkes, B., Zeltzer, L. 2008; 33 (4): 408-421
Introduction of a Pediatric Palliative Care Curriculum for pediatric residents JOURNAL OF PALLIATIVE MEDICINE Schiffman, J. D., Chamberlain, L. J., Palmer, L., Contro, N., Sourkes, B., Sectish, T. C. 2008; 11 (2): 164-170
Armfuls of time: The psychological experience of the child with a life-threatening illness 1st International Middle East Conference on Paediatric Palliative Care Sourkes, B. M. KARGER. 2007: 3741
Psychotherapy in pediatric palliative care CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA Brown, M. R., Sourkes, B. 2006; 15 (3): 585-?
Hospital staff and family perspectives regarding quality of pediatric palliative care PEDIATRICS Contro, N. A., Larson, J., Scofield, S., Sourkes, B., Cohen, H. J. 2004; 114 (5): 1248-1252
A child and parent illustrating non-compliance with treatment: understanding non-compliance with treatment BULLETIN DU CANCER Oppenheim, D., Hartmann, O., Ablin, A., Sourkes, B. 2002; 89 (6): 643-647
Family perspectives on the quality of pediatric palliative care ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Contro, N., Larson, J., Scofield, S., Sourkes, B., Cohen, H. 2002; 156 (1): 14-19